What are the management options for plantar fasciitis?

Management of Plantar Fasciitis

The most effective management of plantar fasciitis involves a progressive approach starting with conservative measures such as plantar fascia-specific stretching, calf stretching, appropriate orthotics, and night dorsiflexion splinting, with more invasive treatments reserved for recalcitrant cases. 1

Clinical Presentation and Diagnosis

• Plantar fasciitis presents as stabbing, non-radiating pain in the proximal medioplantar surface of the foot, typically worst with the first few steps in the morning 2
• Pain often worsens at the end of the day and after prolonged standing or activity 2
• Physical examination reveals tenderness to palpation at the proximal plantar fascial insertion at the anteromedial calcaneus 2
• Diagnosis is predominantly clinical; imaging is only necessary for cases that persist beyond 3 months despite treatment 2

First-Line Treatment Options

1. Stretching Exercises:

   • Plantar fascia-specific stretching: Pull toes toward shin while seated, holding for 10 seconds, repeat 10 times, 3 times daily 1
   • Calf stretching: Stand facing wall with affected leg behind, keep heel down while leaning forward 1

2. Physical Modalities:

   • Ice massage: Roll foot over frozen water bottle for 5-10 minutes, 3-4 times daily 2
   • Activity modification to decrease repetitive loading of the plantar fascia 1

3. Medications:

   • NSAIDs for pain relief and to reduce discomfort 2

4. Supportive Devices:

   • Appropriate footwear with adequate arch support 3
   • Night dorsiflexion splints to maintain plantar fascia stretch overnight 1
   • Arch supports or orthotics for biomechanical correction 3

Second-Line Treatment Options

For cases that fail to respond to 4-6 weeks of first-line therapy:

1. Corticosteroid Injections:

   • Can provide short-term pain relief
   • Must be weighed against risks of fat pad atrophy and plantar fascia rupture 1
   • Should be limited in number and frequency

2. Extracorporeal Shock Wave Therapy (ESWT):

   • Ultrasonography-guided focal ESWT is useful for chronic cases 1
   • Consider referral for this treatment in recalcitrant cases (persisting >3 months)

Third-Line Treatment Options

For cases persisting beyond 6-12 months despite comprehensive treatment:

1. Surgical Intervention:
   • Endoscopic fasciotomy may be required when pain continues to limit activity and function despite exhausting non-operative options 2
   • Surgical consultation should be considered only after failure of comprehensive conservative management

Treatment Algorithm

1. Weeks 0-6: First-line conservative measures

   • Daily stretching exercises (plantar fascia and calf)
   • Ice massage
   • NSAIDs
   • Supportive footwear/orthotics
   • Night splints

2. Weeks 6-12: If inadequate improvement

   • Continue first-line measures
   • Consider corticosteroid injection (limited to 1-2 injections)
   • Evaluate for biomechanical factors requiring correction

3. Beyond 12 weeks: For persistent cases

   • Referral for ESWT
   • Consider diagnostic ultrasound if not previously performed
   • Evaluate for alternative diagnoses

4. Beyond 6-12 months: For refractory cases

   • Surgical consultation for possible endoscopic fasciotomy

Important Considerations

• With proper treatment, approximately 80% of patients improve within 12 months 2
• The shorter the interval between symptom onset and treatment initiation, the quicker the resolution 3
• Risk factors include limited ankle dorsiflexion, increased BMI, and prolonged standing 2
• Identify and address predisposing conditions such as obesity, tight Achilles tendon, pes cavus, and pes planus 4
• Avoid aggressive activities during the treatment phase regardless of chosen treatment modality 1

Pitfalls to Avoid

• Delaying treatment initiation, as earlier intervention leads to faster resolution 3
• Overreliance on corticosteroid injections due to risks of fat pad atrophy and fascia rupture 1
• Premature consideration of surgical options before exhausting conservative measures
• Failure to address underlying biomechanical factors and activity modifications

Remember that plantar fasciitis is predominantly a degenerative rather than inflammatory condition (more accurately termed "plantar fasciopathy"), which should guide treatment expectations and approaches 2.